LARYNGEAL PAPILLOMA

Laryngeal Papilloma is the most common benign epithelial neoplasms affecting the larynx
and upper respiratory tract. The malignant degeneration to squamous cell carcinoma can occur, but
it is very rare. Human Papiloma Virus (HPV) type 6 and 11 were comfirmed as etiologyc agent and it
is possible to get HPV type 16 and 18 also, but in lesser extent. The laryngeal papilloma has several
symptoms, such as changes in phonation, dyspnea, dysphagia, cough and complain of stridor. This
case is easily recurrent even after surgical procedures. Moreover, it tends to spread to the adjacent
tissues. It is divided in 2 types :

Adult type : it is more often single, recurs less often, and less likely to spread

Juvenile type : multiple lesions could be found with extensive growth and rapid
recurrence. It may remit spontaneously or persist, even until elderly.

JRRP (Juvenile Recurrent Respiratory Papilloma) is identified in infancy or childhood

characterized by extensive involvement of the larynx with frequent recurrences. Commonly at 2 4
years old and equally common in boys and girls who are younger than 12 years of age. This kind of
papilloma is generally more aggressive than adult-onset RRP. The earlier it presents, papilloma tends
to be more aggresive
From macroscopic feature we can see the mass like murbeys, white to grey in colours and in
some cases red. Occurs at plica vocalis anterior or sub glotic area and also at plica ventricularis or
arytenoid . Manifest of the deseases usually presents as hoarseness, and more advance cases
manifest with cough and stridor.

RRP should be considered in any patient in any ages who presents with hoarseness, voice
change, and shortness of breath, especially in young children who have feeding difficulties, failure to
thrive, recurrent pneumonia, or dysphagia. Although papillomas are benign, their rapid growth and
proliferation can cause obstruction of the airway that can lead to asphyxiation if not treated, so a
tracheotomy may be necessary in some cases

The diagnose is based on :

1. Anamnesis
2. Clinical Symptoms : hoarseness, voice change, cough, stridor, shortness of breath
3. Physical Examination

a. Indirect laryngoscopy to identify glottic and supraglottic lessions

b. Nasoendoscopy

i. Papillomas can identify at the limen vestibuli, nasopharyngeal surface of the

soft palate, midzone of the laryngeal surface of the epiglottis, upper and
lower margins of the ventricle, under surface of the vocal folds, carina, and
at bronchial spurs

ii. pink or white, sessile or exophytic lesions, pedunculated or broad based,

with small, frondlike projections
 4. Histopatologic

a. Composed of multiple fingerlike projections of nonkeratinized stratified squamous

epithelium overlying a vascularized core of connective tissue stroma.

b. The basal epithelium can be normal to hyperplastic, and cellular differentiation can
be normal or abnormal with variable expression and production of keratins. Mitotic
figures at the basal layer.

TREATMENT

The goal of RPP treatment is to remove as much disease as possible to improve or maintain
respiratory function, while preserving laryngeal function with additional ablation of the root of the
papilloma in hope of preventing regrowth.

1. Tracheostomy

Tracheostomy is a procedures used for lifesaving treatment of upper-airway obstruction

which performed at patient with critical ill. This surgical procedures is to opening the anterior wall of
the trachea to facilitate ventilation. The opening was at the second third ring of the trachea. In
some cases of RRP tracheostomy is necessary. The need for tracheotomy arises when the growth of
the mass causing respiratory distress that is due to significant airway obstruction particullarly
stadium 2 and 3 Jackson criteria.

Tracheostomy indication

a. By pass the larynx obstruction

b. Clean and remove secretion from broncus

c. To set a respirator

d. Minimalized dead air space

Tracheostomy technique

Surgical tracheostomy (ST) is usually performed in the operating room on a patient under
general anesthesia, but it may be performed at the bedside in the intensive care unit.

a. Prophylactic antibiotics specific administered 30 60 min prior to skin incision.

b. The patients shoulders are elevated with head extension at atlanto occipital joint to
elevating the larynx and exposing more of the upper trachea.
c. Antiseptic and aseptic procedures at operation site.
d. Local anesthesia with a vasoconstrictor infiltrated into the skin and deeper tissues to
reduce the amount of bleeding during the procedure.
e. The skin of the neck over the 2nd tracheal ring is identified, and a vertical incision about
23 cm in length is created. Incision made at the middle of the neck from inferior of the
cricoid to suprasternal fossa. Sharp dissection following the skin incision to cut across the
platysma muscle, with bleeding controlled by hemostats and ties or electocautery.
 f. Blunt dissection parallel to the long axis of the trachea is then used to spread the
submuscular tissues until the thyroid isthmus is identified. If the gland lies superior to
the 3rd tracheal ring, it can be bluntly undermined and retracted superiorly to gain
access to the trachea. If the isthmus overlies the 2nd and 3rd ring of the trachea, it must
be mobilized and either a small incision made to clear a space for the tracheostomy.
g. There are 2 types of tracheal entry is usually used for surgical tracheostomy.
The first method is to complete removal of the anterior part of one of the tracheal
rings to create the stoma, and creation of a flap with the severed part of the ring. In the
ring-removal approach, the ring is lifted with a tracheal hook and 2 circumferential
sutures are placed around the ring laterally. The portion of ring between the secured
sutures is then cut and removed, leaving a hole in the anterior tracheal wall for the
tracheostomy tube. The sutures are left in place and used to provide counter traction on
the trachea as the tube is forced into the lumen. The ring sutures are cut long and left
out of the wound or used to secure the tracheostomy tube.
The second one is creating a tracheal wall flap sutured to the skin. This is done by
incising the fascia over the superior ring and entering the trachea along its inferior
margin. This becomes the outer lip of the flap. Lateral cuts through the lower ring
complete the sharp dissection. The flap thus created is reflected downward and attached
with several sutures to the skin of the neck.
h. After the stoma made, insert the canule n fix it to the patient neck. Apply the dressing
for the wound healing.

2. Surgical Extirpation with CO2 Laser

Used with suspension microlaryngoscopy,the CO2 laser permits precise ablation of lesions and
excellent hemostasis. With a wavelength of 10,600 nm, the CO2 laser converts light into thermal
energy, and targets water in treated tissues, which results in tissue destruction by vaporization. The
laser can be used in a defocused mode to debulk massive RRP, and then switched to a focused spot
size to ablate residual RRP in areas in which minimal damage to laryngeal structures is desired .
Because the virus lives in the normal appearing tissue surrounding the papilloma, recurrence is likely,
and repeated endoscopic removal is often necessary

3. Photodynamic Therapy

Described in the early 1900s, PDT has been used to destroy neoplasms by light activation of a
photosensitive dye that selectively concentrates in tumor cells. Vascular and tumor destruction result
from the vascular stasis that occurs with the in situ generation of singlet oxygen by laser activation of
the photosensitizer

4. Anti Viral

Cidofovir [(S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine] is an antiviral medication

that is used to treat viral infections. To treat RRP, cidofovir has been injected directly into the
papilloma (locally) at the time of endoscopy
Durbin G.C, Techniques for Performing Tracheostomy, Respiratory care, april 2005 vol 50 no
4. Hal 488 496